Clinical Presentation
Introduction
While most people think only of type 1 and type 2 diabetes, there are actually many forms of diabetes. Diabetes types are generally unified by hyperglycemia, but their pathogenesis can be quite distinct. Because primary care clinicians provide the overwhelming majority of diabetes care, it is essential that they know how to identify and treat the various forms. This first chapter examines the value of clinical presentations. When the clinician is aware of the different forms of diabetes, they are better able to identify key features and make correct diagnoses.
Case 1. Type 2 Diabetes in Adults
“My heart attack gave me diabetes.”
A 58-year-old man recently presented to the emergency room with substernal chest pain that began while he was working in the yard. The chest pain was associated with nausea, diaphoresis, and shortness of breath. He had an anterior wall STEMI (ST-elevation myocardial infarction). This was successfully treated with PTCA (percutaneous transluminal coronary angioplasty)/stent placement. While he was in the hospital, he was surprised to learn that he had diabetes. This was not part of his medical history in the past. His glucose in the emergency room was 234 mg/dL and his hemoglobin A1c was 8.4%. Glucose readings in the hospital ran between 150 and 260 mg/dL. He presented 1 week later for hospital follow-up.
Prior to the hospitalization he had no known past medical history and was not taking any medications regularly. In the hospital, he was put on a statin, angiotensin-converting enzyme inhibitor (ACEI), and an antiplatelet agent.
Medications (prescribed on discharge): metformin 500 mg bid (not started this yet), lipitor 40 mg daily, clopidogrel 75 mg daily, lisinopril 20 mg daily, and ASA (acetylsalicylic acid) 325 mg daily
Allergies: none
Family Medical History: premature atherosclerotic cardiovascular disease, hypertension, dyslipidemia, and type 2 diabetes in his family; his brother and his father both had myocardial infarctions in their 50s.
Social History: nonsmoker, drinks 2 to 4 beers 3 times per week after work, fast-food diet priorly, no regular physical activity, lives with his wife of 25 years; he works as an accountant.
He wants to understand if he really does have diabetes. He has heard that statins give people diabetes and is wondering if this happened to him. Since coming home, his wife has put him on a very strict low-fat, calorie-controlled diet. He is scheduled to start cardiac rehab next week. He was given a glucometer upon discharge but not shown how to use it, so he has not started checking his blood sugars at home.
Physical Exam: Ht. 5′7″, Wt. 195 lb, BMI 30.5, T 98.6, P 88, R 15, BP 125/80
CV: heart rate and rhythm are regular; normal peripheral pulses, no bruits
RESP: lungs CTA anterior and posterior
Skin: bruising noted in left groin from his cardiac catheterization
Otherwise: normal exam
Lab Values (from hospital):
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CASE QUESTIONS1. Does he indeed have diabetes mellitus?
View Answer
1. While the diagnosis of diabetes usually requires two tests separated by time, the fact that he has an elevated random glucose well above 200 mg/dL and hemoglobin A1c at 8.4% confirms that he has had hyperglycemia for a minimum of 3 months prior to the lab test. Repeating any of the qualifying labs to confirm the diagnosis is an option including a fasting glucose, a 2-hour postprandial glucose, a glucose tolerance test (GTT), or a hemoglobin A1c. However, considering his current levels, this is largely unnecessary (Table 1.1 and Figure 1.1).
2. Is his presentation common for type 2 diabetes mellitus?
View Answer
2. More than 10% of the US adult population had diabetes mellitus in 2020. Another 35% had prediabetes.3 Importantly, more than 20% of those individuals with active diabetes mellitus did not know they had diabetes (undiagnosed).4
The most common presentation of type 2 diabetes is an asymptomatic finding on a routine screening lab. It is also worth noting that one-third of people with diabetes find out that they have diabetes in association with the presentation of a diabetes-related complication. It has also been reported that 25% of people who present with a heart attack find out that they have diabetes at that time.3
3. Did the statin give him diabetes?
View Answer
3. While there have been reports that statins can raise glucose levels and even tip someone into new onset type 2 diabetes, it is very unlikely in this case. Prior to his hospitalization, he was not taking any medications and his glucose and A1c were elevated. The short period of time he took the statin in the hospital would not have had a significant impact on his glucose and HbA1c.
A 2009 study looked at changes in glucose from statin use in people with and without diabetes. The net increase in fasting glucose was 7 mg/dL in people with known diabetes and 2 mg/dL in people without diabetes.5,6 While this is a significant increase, the benefits from statins far outweigh the potential adverse effect of hyperglycemia. It is unlikely that statins will increase this risk in people who do not have insulin resistance already.7 It is worth noting that this study was completed within the Veterans health system, which is known to have substantially higher rates of diabetes and prediabetes.6
4. How to tell your patient that he does in fact have type 2 diabetes?
View Answer
4. Denial, fear, and anger are common reactions to being diagnosed with a serious health condition, like diabetes. If the diagnosis is unexpected, as in the case for this patient, he may try to find an alternative explanation or minimize its importance. This is a normal way of coping when first diagnosed; however, if the denial or minimization of diabetes goes on too long, your patient will increase the likelihood of serious diabetes complications. This is particularly relevant for this case given adult men tend to have the most difficulty accepting a diagnosis of diabetes. As a clinician, the best coping strategies you can offer your patient are to go slow with recommendations for diet and physical activity modification (everything does not need to be fixed overnight), manage stress and anxiety, refer to diabetes education, identify the right support network, and involve family members in the management plan.8
TABLE 1.1 Diagnostic Criteria for Diabetes1 | |||||||||||||||
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 FIGURE 1.1. Trends in age-adjusted prevalence of diagnosed diabetes, undiagnosed diabetes, and total diabetes among adults aged 18 years or older, United States, 1999 to 2016. Diagnosed diabetes was based on self-report. Undiagnosed diabetes was based on fasting plasma glucose and A1c levels among people self-reporting no diabetes. (Reproduced from CDC. Prevalence of Both Diagnosed and Undiagnosed Diabetes. 2021. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html.) |
5. What are the next steps for this patient?
View Answer
5. His recovery should start with cardiac rehabilitation including diabetes education, medical nutrition therapy, moderation of alcohol intake, and encouragement to participate in at least 150 minutes of moderately vigorous physical activity per week.
Concomitant pharmacotherapy should also be initiated. Historically, this approach includes the use of metformin as foundational therapy, which certainly could be used in this case. However, in light of recent cardiovascular outcome trials and changes in guidelines, this patient also has a compelling indication for a medication that has been shown to have benefit to reduce secondary atherosclerotic cardiovascular events. These medications could include one of the SGLT-2 (sodium-glucose cotransporter-2) inhibitors or GLP (glucagon-like peptide)-1 receptor agonists with proven benefit in cardiovascular risk reduction.9 We will discuss this topic much more later in the book (see Chapter 4 for further discussion on this point).
ANSWERS AND EXPLANATIONS1. While the diagnosis of diabetes usually requires two tests separated by time, the fact that he has an elevated random glucose well above 200 mg/dL and hemoglobin A1c at 8.4% confirms that he has had hyperglycemia for a minimum of 3 months prior to the lab test. Repeating any of the qualifying labs to confirm the diagnosis is an option including a fasting glucose, a 2-hour postprandial glucose, a glucose tolerance test (GTT), or a hemoglobin A1c. However, considering his current levels, this is largely unnecessary (Table 1.1 and Figure 1.1).
2. More than 10% of the US adult population had diabetes mellitus in 2020. Another 35% had prediabetes.3 Importantly, more than 20% of those individuals with active diabetes mellitus did not know they had diabetes (undiagnosed).4
The most common presentation of type 2 diabetes is an asymptomatic finding on a routine screening lab. It is also worth noting that one-third of people with diabetes find out that they have diabetes in association with the presentation of a diabetes-related complication. It has also been reported that 25% of people who present with a heart attack find out that they have diabetes at that time.3
3. While there have been reports that statins can raise glucose levels and even tip someone into new onset type 2 diabetes, it is very unlikely in this case. Prior to his hospitalization, he was not taking any medications and his glucose and A1c were elevated. The short period of time he took the statin in the hospital would not have had a significant impact on his glucose and HbA1c.
A 2009 study looked at changes in glucose from statin use in people with and without diabetes. The net increase in fasting glucose was 7 mg/dL in people with known diabetes and 2 mg/dL in people without diabetes.5,6 While this is a significant increase, the benefits from statins far outweigh the potential adverse effect of hyperglycemia. It is unlikely that statins will increase this risk in people who do not have insulin resistance already.7 It is worth noting that this study was completed within the Veterans health system, which is known to have substantially higher rates of diabetes and prediabetes.6
4. Denial, fear, and anger are common reactions to being diagnosed with a serious health condition, like diabetes. If the diagnosis is unexpected, as in the case for this patient, he may try to find an alternative explanation or minimize its importance. This is a normal way of coping when first diagnosed; however, if the denial or
minimization of diabetes goes on too long, your patient will increase the likelihood of serious diabetes complications. This is particularly relevant for this case given adult men tend to have the most difficulty accepting a diagnosis of diabetes. As a clinician, the best coping strategies you can offer your patient are to go slow with recommendations for diet and physical activity modification (everything does not need to be fixed overnight), manage stress and anxiety, refer to diabetes education, identify the right support network, and involve family members in the management plan.8
minimization of diabetes goes on too long, your patient will increase the likelihood of serious diabetes complications. This is particularly relevant for this case given adult men tend to have the most difficulty accepting a diagnosis of diabetes. As a clinician, the best coping strategies you can offer your patient are to go slow with recommendations for diet and physical activity modification (everything does not need to be fixed overnight), manage stress and anxiety, refer to diabetes education, identify the right support network, and involve family members in the management plan.8
TABLE 1.1 Diagnostic Criteria for Diabetes1 | |||||||||||||||
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 FIGURE 1.1. Trends in age-adjusted prevalence of diagnosed diabetes, undiagnosed diabetes, and total diabetes among adults aged 18 years or older, United States, 1999 to 2016. Diagnosed diabetes was based on self-report. Undiagnosed diabetes was based on fasting plasma glucose and A1c levels among people self-reporting no diabetes. (Reproduced from CDC. Prevalence of Both Diagnosed and Undiagnosed Diabetes. 2021. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html.) |
5. His recovery should start with cardiac rehabilitation including diabetes education, medical nutrition therapy, moderation of alcohol intake, and encouragement to participate in at least 150 minutes of moderately vigorous physical activity per week.
Concomitant pharmacotherapy should also be initiated. Historically, this approach includes the use of metformin as foundational therapy, which certainly could be used in this case. However, in light of recent cardiovascular outcome trials and changes in guidelines, this patient also has a compelling indication for a medication that has been shown to have benefit to reduce secondary atherosclerotic cardiovascular events. These medications could include one of the SGLT-2 (sodium-glucose cotransporter-2) inhibitors or GLP (glucagon-like peptide)-1 receptor agonists with proven benefit in cardiovascular risk reduction.9 We will discuss this topic much more later in the book (see Chapter 4 for further discussion on this point).
Case Summary and Closing Points
Type 2 diabetes is a common and, for many, a silent condition. Since most people have no symptoms early in the disease, it is common for clinicians to find and diagnose people at the time of a complication. This may be microvascular (retinopathy,
nephropathy, neuropathy) or macrovascular (acute coronary syndrome or stroke). The key to identifying type 2 diabetes as early as possible is to know the risk factors and use the evidence-based screening recommendations.
nephropathy, neuropathy) or macrovascular (acute coronary syndrome or stroke). The key to identifying type 2 diabetes as early as possible is to know the risk factors and use the evidence-based screening recommendations.
References
1. American Diabetes Association. Standards of Medical Care 2022. Classification and Diagnosis and of Diabetes; 2021. https://diabetesjournals.org/care/article/45/Supplement_1/S17/138925/2-Classification-and-Diagnosis-of-Diabetes
2. CDC. Prevalence of Both Diagnosed and Undiagnosed Diabetes; 2021. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html
3. Norhammar A, Tenerz A, Nilsson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet. 2002;359(9324):2140-2144. doi:10.1016/S0140-6736(02)09089-X
4. CDC. Diabetes Fact Sheet. https://www.cdc.gov/diabetes/data/statistics-report/diagnosed-undiagnosed-diabetes.html
5. Sukhija R, Prayaga S, Marashdeh M, et al. Effect of statins on fasting plasma glucose in diabetic and nondiabetic patients. J Invest Med. 2009;57:495-499.
6. Liu Y, Sayam S, Shao X, et al. Prevalence of and Trends in diabetes among Veterans, United States, 2005-2014. Prev Chronic Dis. 2017;14:E135. doi:10.5888/pcd14.170230
7. Chogtu B, Magazine R, Bairy KL. Statin use and risk of diabetes mellitus. World J Diabetes. 2015;6(2):352-357. doi:10.4239/wjd.v6.i2.352
8. Mathew R, Gucciardi E, De Melo M, Barata P. Self-management experiences among men and women with type 2 diabetes mellitus: a qualitative analysis. BMC Fam Pract. 2012;13:122. doi:10.1186/1471-2296-13-122
9. American Diabetes Association. Standards of Medical Care 2022. Pharmacologic Approach to Glycemic Control. https://diabetesjournals.org/care/article/45/Supplement_1/S125/138908/9-Pharmacologic-Approaches-to-Glycemic-Treatment
Case 2. Type 2 Diabetes in Adolescents
“Where did this rash come from?”
A 14-year-old African American boy presented (with his parents) with concerns about a rash (Figure 1.2). The rash was present on his posterior neck. They were not sure how long it had been there. Recently, his teacher called with concerns about hygiene. He has a history of allergic rhinitis and takes loratadine 10 mg daily as needed.
He was born at term and weighed 9 lb 4 oz. (4196 g). He met all his normal developmental milestones. He has been “big” for as long as the family can remember, noting that his weight gain accelerated starting at age 12.
Medications: loratadine
Allergies: none (medication, latex, food)
Family Medical History: type 2 diabetes in mom, maternal grandmother (MGM), and paternal grandmother (PGM); asthma in dad and brother
Social History: Lives at home with parents and younger sister. Currently in ninth grade. Doing “only ok” at school. Has socially withdrawn this year. No tobacco, alcohol, or recreational drugs. He eats school-supported breakfast and lunch (mom reports this is not usually healthy—pizza, sloppy joes, fries—but they need the help). No regular physical activity. He enjoys online video games. The family’s goal for today’s visit is to “get rid of this rash.”
FIGURE 1.2. Picture of skin lesions. (Used with permission from Goodheart H. Goodheart’s Same-Site Differential Diagnosis, 2nd ed. 2022. Wolters Kluwer.)
Physical Exam: Ht. 5′6″, Wt. 293 lb, BMI 47.3, T 98.6, P 88, R 15, BP 138/80
CV/RESP: exam normal
Skin: velvety hyperpigmented plaques along posterior neck and axilla; pink striae noted on the abdomen and shoulders
GEN: pleasant but withdrawn male; truncal obesity
Prediabetes/Diabetes Diagnosis:
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CASE QUESTIONS1. What is the problem list for this patient?
View Answer
1. The problem list for this patient includes:
a. Obesity
b. Metabolic syndrome
c. Type 2 diabetes
d. Suspected nonalcoholic fatty liver disease
e. Albuminuria
f. Concern about depression
2. Does he have diabetes? If so, what type?
View Answer
2. His glucose value and hemoglobin A1c clearly indicate that he has diabetes. Given that he has a family history of type 2 diabetes, his body habitus matches type 2 diabetes. Further, the fact that he has dyslipidemia and presents with physical characteristics of insulin resistance, the overwhelming likelihood is that he has type 2 diabetes. While it is often thought that children only get type 1 diabetes, we now know that a sizable proportion of children diagnosed with diabetes actually have type 2 diabetes.1 Pediatric obesity is becoming an increasingly common scenario and a significant public health challenge. We are seeing more and more obese adolescents and young adults being diagnosed with metabolic-related diseases such as type 2 diabetes.1,2
Given the clinical presentation, there is no need to do any additional evaluation at this time. If he were to develop catabolic symptoms later, he could be tested for type 1 diabetes (Figure 1.3).
3. What is causing the rash?
View Answer
3. The skin changes are from acanthosis nigricans, a problem related to insulin resistance. It is most commonly seen on the neck, especially the posterior aspect of the neck in the axilla and sometimes in the groin. It may also occur on extensor surfaces.3
The pathophysiology of acanthosis is believed to be related to the excessive stimulation of epidermal keratinocytes and dermal fibroblasts. This stimulation is felt to be a result of excess endogenous insulin and insulin-like growth factor.4 These hormones rise with obesity and insulin resistance. Insulin is itself a growth factor, and it stimulates growth of many cell lines including melanin cells in the epidermis. The skin changes of plaque formation and hyperpigmentation appear when the growth rate exceeds the sloughing of cells causing the skin to thicken and becomes darker.
This rash is often mistaken for dirt or poor hygiene. It is important to recognize that there is no specific agreed upon treatment for acanthosis other than interventions that improve insulin resistance.
4. What are the next steps?
View Answer
4. There is much to consider here. It is important to explain to the patient and his family that acanthosis is a marker of high genetic risk for insulin resistance and type 2 diabetes. This helps to direct attention away from issues about weight and focus on the genetic component of type 2 diabetes. It is important to reinforce that the rash is not hygiene related. It is also important to communicate that there are no simple or direct solutions for the skin changes. The best approach is to address the underlying cause and provide accurate medical information and psychosocial support. Diabetes care guidelines recommended screening adolescents for depression at diagnosis and routine follow-up. Adolescents with type 2 diabetes are at higher risk for depression compared to the general adolescent population. Your patient indicates that he has been more socially withdrawn this year in school, which suggests potential psychosocial concerns. Screening and diagnosing depression is critical given symptoms of depression interfere with the ability to engage in self-care behaviors, like physical activity, following a healthy diet, managing weight, and monitoring blood glucose levels.
 FIGURE 1.3. Trends in the incidence of type 1 and type 2 diabetes in youth, overall and by race/ethnicity, 2002 to 2015. (Adapted Divers J, Mayer-Davis EJ, Lawrence JM, et al. Trends in incidence of type 1 and type 2 diabetes among youths—selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep. 2020;69(6):161-165. doi:10.15585/mmwr.mm6906a3) |
This adolescent and family need a family-based comprehensive approach to address the items noted above with a particular focus on mental health and healthy coping. (This approach will be explored in Chapter 2, Case 2.)
ANSWERS AND EXPLANATIONS1. The problem list for this patient includes:
a. Obesity
b. Metabolic syndrome
c. Type 2 diabetes
d. Suspected nonalcoholic fatty liver disease
e. Albuminuria
f. Concern about depression
2. His glucose value and hemoglobin A1c clearly indicate that he has diabetes. Given that he has a family history of type 2 diabetes, his body habitus matches type 2 diabetes. Further, the fact that he has dyslipidemia and presents with physical characteristics of insulin resistance, the overwhelming likelihood is that he has type 2 diabetes. While it is often thought that children only get type 1 diabetes, we now know that a sizable proportion of children diagnosed with diabetes actually have type 2 diabetes.1 Pediatric obesity is becoming an increasingly common scenario and a significant public health challenge. We are seeing more and more obese adolescents and young adults being diagnosed with metabolic-related diseases such as type 2 diabetes.1,2
Given the clinical presentation, there is no need to do any additional evaluation at this time. If he were to develop catabolic symptoms later, he could be tested for type 1 diabetes (Figure 1.3).
3. The skin changes are from acanthosis nigricans, a problem related to insulin resistance. It is most commonly seen on the neck, especially the posterior aspect of the neck in the axilla and sometimes in the groin. It may also occur on extensor surfaces.3
The pathophysiology of acanthosis is believed to be related to the excessive stimulation of epidermal keratinocytes and dermal fibroblasts. This stimulation is felt to be a result of excess endogenous insulin and insulin-like growth factor.4 These hormones rise with obesity and insulin resistance. Insulin is itself a growth factor, and it stimulates growth of many cell lines including melanin cells in the epidermis. The skin changes of plaque formation and hyperpigmentation appear when the growth rate exceeds the sloughing of cells causing the skin to thicken and becomes darker.
This rash is often mistaken for dirt or poor hygiene. It is important to recognize that there is no specific agreed upon treatment for acanthosis other than interventions that improve insulin resistance.
4. There is much to consider here. It is important to explain to the patient and his family that acanthosis is a marker of high genetic risk for insulin resistance and type 2 diabetes. This helps to direct attention away from issues about weight and focus on the genetic component of type 2 diabetes. It is important to reinforce that the rash is not hygiene related. It is also important to communicate that there are no simple or direct solutions for the skin changes. The best approach is to address the underlying cause and provide accurate medical information and psychosocial support. Diabetes care guidelines recommended screening adolescents for depression at diagnosis and routine follow-up. Adolescents with type 2 diabetes are at higher risk for depression compared to the general adolescent population. Your patient
indicates that he has been more socially withdrawn this year in school, which suggests potential psychosocial concerns. Screening and diagnosing depression is critical given symptoms of depression interfere with the ability to engage in self-care behaviors, like physical activity, following a healthy diet, managing weight, and monitoring blood glucose levels.
indicates that he has been more socially withdrawn this year in school, which suggests potential psychosocial concerns. Screening and diagnosing depression is critical given symptoms of depression interfere with the ability to engage in self-care behaviors, like physical activity, following a healthy diet, managing weight, and monitoring blood glucose levels.
 FIGURE 1.3. Trends in the incidence of type 1 and type 2 diabetes in youth, overall and by race/ethnicity, 2002 to 2015. (Adapted Divers J, Mayer-Davis EJ, Lawrence JM, et al. Trends in incidence of type 1 and type 2 diabetes among youths—selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep. 2020;69(6):161-165. doi:10.15585/mmwr.mm6906a3) |
This adolescent and family need a family-based comprehensive approach to address the items noted above with a particular focus on mental health and healthy coping. (This approach will be explored in Chapter 2, Case 2.)
Case Summary and Closing Points
This is a case wherein the initial presentation of type 2 diabetes is not glucose-related. It is worth remembering that skin changes are commonly the first signs of diabetes especially in at-risk populations. Further, it is important to remember that when type 2 diabetes is diagnosed in adolescents and young adults the condition is more severe and should be treated promptly and thoroughly. Optimally, this includes a team-based approach that addresses the health needs of the entire family.
References
1. Mayer-Davis EJ, Lawrence JM, Dabelea D, et al. Incidence Trends of type 1 and type 2 diabetes among youths, 2002-2012. N Engl J Med. 2017;376(15):1419-1429.
2. Divers J, Mayer-Davis EJ, Lawrence JM, et al. Trends in incidence of type 1 and type 2 diabetes among youths—selected counties and Indian reservations, United States, 2002-2015. MMWR Morb Mortal Wkly Rep. 2020;69(6):161-165. doi:10.15585/mmwr.mm6906a3
3. Duff M, Demidova O, Blackburn S, Shubrook JH. Cutaneous manifestations of diabetes. Clin Diabetes. 2015;33(1):40-48.
4. Hines A, Alavi A, Davis MDP. Cutaneous manifestations of diabetes. Med Clin North Am. 2021;105(4):681-697. doi:10.1016/j.mcna.2021.04.008
5. Anderson BJ, McKay SV. Psychosocial issues in youth with type 2 diabetes mellitus. Curr Diab Rep. 2009;9:147-153.
Case 3. Type 1 Diabetes in Children
“We thought he had the flu.”
An 8-year-old boy presented to the emergency room with a stomach flu that did not seem to be resolving. His mom explained that he started acting differently a couple of weeks ago. He came home from a sleepover, and she noticed that he was drinking a lot and peeing a lot. He also seemed to be more hungry than normal. These behaviors persisted for several weeks. Also, mom noticed that he was losing weight. While changes in eating were common for him with growth spurts, weight loss was not. More recently things worsened, as he complained of abdominal pain and nausea and vomited several times.
Medications: none
Allergies: none
Family Medical History: immediate family in good health; Alzheimer disease in MGM
Social History: lives with his parents, one older sister, and one younger brother; normal developmental milestones; picky eater; doing well in school, fourth grade.
Physical Exam: in emergency room
Vitals: HR 124, R 28, T 98.6 F, BP 90/60, Ht. 52 in, Wt. 54 lb, BMI 16
General: appears dehydrated, lying on gurney, sluggish but cooperative
HEENT: oral mucosa dry and breath smells “fruity”; eyes appear sunken
CV: rapid but regular
RESP: clear with Kussmaul breathing
Abdomen: BS (bowel sounds) active, mild diffuse tenderness, no localization
Neuro: he is arousable, oriented to person and place; no focal neurologic deficits or nuchal rigidity
Lab Values:
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CASE QUESTIONS1. What is making him sick?
View Answer
1. This child has the “polys,” a presentation of polyuria, polydipsia, and polyphagia with weight loss. This is the classic presentation of type 1 diabetes. According to clinical presentation and labs, he is in an anion gap ketoacidosis—mostly likely diabetic ketoacidosis (DKA).
When severe hyperglycemia arises from an absolute deficiency of insulin, the body starts to use alternate fuels such as ketones to fuel the brain and other key areas. This process causes unopposed lipolysis and oxidation of free fatty acids and thereby results in ketone body production and a subsequent increased anion gap metabolic acidosis. If insulin deficiency is persistent and hyperglycemia becomes prominent, the body starts to develop catabolic symptoms (the “polys”) and weight loss. If this persists, the body becomes acidotic. Acidosis can commonly lead to symptoms such as nausea, abdominal pain, and vomiting. Most people who present with DKA as their initial finding of diabetes assume that something else is causing these symptoms such as a stomach flu.
Once the acidosis is treated, his gastrointestinal symptoms are likely to get better. He also needs fluid resuscitation. Once the fluid deficit is treated and he receives an adequate amount of insulin to prevent catabolic symptoms, his “polys” will improve.
2. Does he have diabetes? If so, what type?
View Answer
2. Glucose screening for diabetes when a child is sick is not optimal as children can have substantial hyperglycemia under severe stress.1 In this case, with a concomitant HbA1c of 9.6%, we know that the patient has been hyperglycemic for 3 months—even longer than his poly symptoms. We can confidently diagnose him with diabetes based on this and his presentation in DKA.
DKA is one of the most common presentations of new diagnosis of type 1 diabetes. Based on his lack of family history of diabetes and the presentation at age 8 with DKA, with no signs of insulin resistance, he likely has type 1 diabetes. However, there are a couple of factors to keep in mind. There is a ketosis-prone (DKA-prone) form of type 2 diabetes, albeit this is more common in young adults who are phenotypically more like type 2. Further, COVID-19 infections have been shown to increase rates of type 1 and type 2 diabetes as well as cases of sustained hyperglycemia that eventually completely resolve.2,3
His presentation is most consistent with type 1 diabetes. He should be treated as having type 1 diabetes in both the inpatient and outpatient setting until further evaluation can be completed when he is more stable.
3. What are best practices for communicating with the family regarding a new diagnosis of diabetes?
View Answer
3. Receiving a lifelong diagnosis like type 1 diabetes can be a traumatic experience for the family as well as the child. The most important thing to communicate while the child is in DKA is the child appears to have type 1 diabetes; the most immediate concern is to stabilize them; and there will be an opportunity to discuss their condition and its implications once the child is stabilized—typically the next day. Providing more information on the first day is not likely to be beneficial, as the shock of the diagnosis and the child’s condition fully occupies the family’s attention. Waiting to start diabetes education when the child is more stable is important as it allows all relevant family members to be present, improves their ability to hear the messaging, and allows everyone in the family to take in the same information. This is especially important as there are many misconceptions about what causes type 1 diabetes and what constitutes optimal treatment.
Important messages on day 2 (when the family can be assembled with the child and the child is feeling better) include the following: (1) the type of diabetes (if known); (2) how it will be treated; (3) information about whether or not it can be cured; and (4) the specific and likely impacts on the child’s and family’s daily activities. Related to message 4, the child and his family may experience a variety of feelings—fear, anger, guilt, helplessness, anxiety, etc.—about the diagnosis and what’s to come. As a provider, you can help the child and family cope with the diagnosis by acknowledging their feelings and reinforcing that the child will continue to be a contributing member of society.
Common education and treatment goals before discharge include (1) the ability of the child and key family members to check glucose, inject insulin, and check ketones; (2) knowledge of common symptoms of hyperglycemia and hypoglycemia; and (3) knowledge of how to treat hyperglycemia and hypoglycemia. There is much more to learn, but these basics are most critical to help the family feel safe enough to go home.
4. What are the next steps?
View Answer
4. Both the child and their family will have to learn many new skills and incorporate them into their daily lives for the rest of the child’s life. Recognizing the enormity of this situation, it is essential to practice patience while providing instruction for small steps that the family can achieve in a timely manner. These new skills include learning about carbohydrates, glucose monitoring, and calculating and injecting insulin—this will include basal insulin, mealtime insulin, and correction insulin. The child and family members will need to learn how to identify and treat hyperglycemia and hypoglycemia (as stated above).
All of the organizations that interact with the child will also need written instructions on how to assist the child (school, day care, extracurricular activities). A newly diagnosed child can expect to be seen every 3 to 5 days for the first 2 weeks. Children and family members should be encouraged to bring in questions with the goal of honing their abilities incrementally. Early diabetes education, in the hospital and at home, is critically important to build a strong set of diabetes self-care skills increasing the comfort and confidence of the child and family.
ANSWERS AND EXPLANATIONS1. This child has the “polys,” a presentation of polyuria, polydipsia, and polyphagia with weight loss. This is the classic presentation of type 1 diabetes. According to clinical presentation and labs, he is in an anion gap ketoacidosis—mostly likely diabetic ketoacidosis (DKA).
When severe hyperglycemia arises from an absolute deficiency of insulin, the body starts to use alternate fuels such as ketones to fuel the brain and other key areas. This process causes unopposed lipolysis and oxidation of free fatty acids and thereby results in ketone body production and a subsequent increased anion gap metabolic acidosis. If insulin deficiency is persistent and hyperglycemia becomes prominent, the body starts to develop catabolic symptoms (the “polys”) and weight loss. If this persists, the body becomes acidotic. Acidosis can commonly lead to symptoms such as nausea, abdominal pain, and vomiting. Most people who present with DKA as their initial finding of diabetes assume that something else is causing these symptoms such as a stomach flu.
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